Collaboration improves the quality of care: methodological challenges and evidence from US health care research

Role understanding and effective communication as core competencies for collaborative practice

The ability to work with professionals from other disciplines to deliver collaborative, patient-centred care is considered a critical element of professional practice requiring a specific set of competencies. However, a generally accepted framework for collaborative competencies is missing, which makes consistent preparation of students and staff challenging. Some authors have argued that there is a lack of conceptual clarity of the "active ingredients" of collaboration relating to quality of care and patient outcomes, which may be at the root of the competencies issue. As part of a large Health Canada funded study focused on interprofessional education and collaborative practice, our goal was to understand the competencies for collaborative practice that are considered most relevant by health professionals working at the front line. Interview participants comprised 60 health care providers from various disciplines. Understanding and appreciating professional roles and responsibilities and communicating effectively emerged as the two perceived core competencies for patient-centred collaborative practice. For both competencies there is evidence of a link to positive patient and provider outcomes. We suggest that these two competencies should be the primary focus of student and staff education aimed at increasing collaborative practice skills.

What are the most effective strategies for improving quality and safety of health care?

There is now a plethora of different quality improvement strategies (QIS) for optimizing health care, some clinician/patient driven, others manager/policy-maker driven. Which of these are most effective remains unclear despite expressed concerns about potential for QIS-related patient harm and wasting of resources. The objective of this study was to review published literature assessing the relative effectiveness of different QIS. Data sources comprising PubMed Clinical Queries, Cochrane Library and its Effective Practice and Organization of Care database, and HealthStar were searched for studies of QIS between January 1985 and February 2008 using search terms based on an a priori QIS classification suggested by experts. Systematic reviews of controlled trials were selected in determining effect sizes for specific QIS, which were compared as a narrative meta-review. Clinician/patient driven QIS were associated with stronger evidence of efficacy and larger effect sizes than manager/policy-maker driven QIS. The most effective strategies (>10% absolute increase in appropriate care or equivalent measure) included clinician-directed audit and feedback cycles, clinical decision support systems, specialty outreach programmes, chronic disease management programmes, continuing professional education based on interactive small-group case discussions, and patient-mediated clinician reminders. Pay-for-performance schemes directed to clinician groups and organizational process redesign were modestly effective. Other manager/policy-maker driven QIS including continuous quality improvement programmes, risk and safety management systems, public scorecards and performance reports, external accreditation, and clinical governance arrangements have not been adequately evaluated with regard to effectiveness. QIS are heterogeneous and methodological flaws in much of the evaluative literature limit validity and generalizability of results. Based on current best available evidence, clinician/patient driven QIS appear to be more effective than manager/policy-maker driven QIS although the latter have, in many instances, attracted insufficient robust evaluations to accurately determine their comparative effectiveness.

Effects on work resumption of a co-operation project in vocational rehabilitation. Systematic, multi-professional, client-centred and solution-oriented co-operation

PURPOSE

The present aim was to evaluate the effect of systematic multi-professional co-ordinated rehabilitation (the Stockholm Co-operation Project) on the number of days' sick leave during the first and second half-years after the rehabilitation co-ordination period, compared to the year before. Another aim was to evaluate the economic effects at national level.

METHOD

A matched-pairs design was used. The study group was based on 64 rehabilitees employed by a public employer in Stockholm, who took part in a systematic multi-professional co-operation project. To obtain pairs, the 64 individuals were individually matched with 64 people who received conventionally organised rehabilitation. Thus, there were 128 subjects altogether.

RESULTS

The study group had substantially less sick leave days per month than the comparison group during the second half-year after the rehabilitation co-ordination period. The effect was even greater in a subgroup with more previous sick leave. During the first half-year after the intervention the comparison group had relatively more sick leave. No effect was found for a subgroup with less previous sick leave. The economic benefit of the intervention was estimated to 1,278 euros per month and person based on the whole group, and to 2,405 euros per month and person based on those with more sick leave.

CONCLUSIONS

People who undergo co-ordinated rehabilitation have more working days after the intervention period than those with conventional rehabilitation. This way for rehabilitation actors to co-operate gives better outcomes for rehabilitation cases with long previous sick leave, but not for cases with less previous sick leave. It also generates economic gains at several levels.

Effectiveness of pre-licensure interprofessional education and post-licensure collaborative interventions

In this paper we scanned and summarized the empirical research evidence and found that the effects of pre-licensure interprofessional education on patient/client care are unknown. In contrast, for post-licensure collaboration interventions, there is a growing body of evidence suggesting positive effects on the delivery of care. The coverage of this latter evidence, however, is patchy, being especially weak in primary care. In interprofessional education, where policy level interventions have been value driven for the last half century, we have identified a base of evidence for the effectiveness of certain post-licensure collaboration interventions; this evidence is lacking for pre-licensure interprofessional education. If interventions and policies for both pre-licensure interprofessional education and post-licensure collaboration are implemented without accompanying rigorous evaluation research, we will remain mired in this same uncertainty into the future.

Interdisciplinary collaboration between primary care, social insurance and social services in the rehabilitation of people with musculoskeletal disorder: Effects on self-rated health and physical performance

Previous research shows there can be good results from co-financing between welfare sectors on the perceived quality of interprofessional collaboration. However, little is known about the impact on patient outcome of such schemes. This study aimed to assess whether co-financed teams with personnel from primary care, social insurance and social services have any effect on patients' health status. A comparative study of patients attending health care centres with and without a co-financed collaboration model was carried out. Although research has shown positive results from co-financed collaboration on staff and organization, we could not find that this new interdisciplinary team structure gave a better patient health outcome than conventional care.

Evaluation framework for a multi-site practice-based interprofessional education intervention

The interprofessional literature suggests that there is a lack of evidence of the effectiveness of interprofessional education (IPE) on patient outcomes and critiques the methodology used to determine the evidence. This paper describes and critiques a comprehensive evaluation of a practice-based IPE intervention. The evaluation was challenged by the complexity of the project such as having multiple sites with great variability in settings and participants which required a multifaceted evaluation approach. Rather than reporting evaluation findings, this paper discusses the methodological successes and challenges of the evaluation framework used. The evaluation consisted of four components: process, outcomes, context and systems evaluation. A mixed method approach was used to collect information from a variety of data sources. Each evaluation component captured distinctive but complementary aspects of the intervention, providing a more complete understanding of the intervention. However, challenges also emerged, in particular for the outcomes component. Discussion of the challenges and benefits of each evaluation component are intended to inform future evaluation designs of complex practice-based IP education interventions. Specifically, adding systems concepts into evaluation can strengthen the evidence base of the effectiveness of IP education on IP practice and patient outcomes.

Whose Outcomes are They Anyway? Report of the Pilot Evaluation of a Joint Service

Health and social care partnership working is often predicated on the notion that it improves outcomes for service users. Yet there is a lack of evidence linking partnerships to changes in outcomes. Against this background, the Health Services Management Centre at the University of Birmingham designed the Partnership Outcomes Evaluation Toolkit (POET) specifically to evaluate health and social care partnerships in terms of service user outcomes. This paper reports on the field testing of POET with Sandwell Integrated Support Service. This research provided a number of interesting insights into this service, and indicated some dissonance between staff and service user and carer expectations.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.

A model and typology of collaboration between professionals in healthcare organizations

Background

The new forms of organization of healthcare services entail the development of new clinical practices that are grounded in collaboration. Despite recent advances in research on the subject of collaboration, there is still a need for a better understanding of collaborative processes and for conceptual tools to help healthcare professionals develop collaboration amongst themselves in complex systems. This study draws on D'Amour's structuration model of collaboration to analyze healthcare facilities offering perinatal services in four health regions in the province of Quebec. The objectives are to: 1) validate the indicators of the structuration model of collaboration; 2) evaluate interprofessional and interorganizational collaboration in four health regions; and 3) propose a typology of collaboration

Methods

A multiple-case research strategy was used. The cases were the healthcare facilities that offer perinatal services in four health regions in the province of Quebec (Canada). The data were collected through 33 semi-structured interviews with healthcare managers and professionals working in the four regions. Written material was also analyzed. The data were subjected to a "mixed" inductive-deductive analysis conducted in two main stages: an internal analysis of each case followed by a cross-sectional analysis of all the cases.

Results

The collaboration indicators were shown to be valid, although some changes were made to three of them. Analysis of the data showed great variation in the level of collaboration between the cases and on each dimension. The results suggest a three-level typology of collaboration based on the ten indicators: active collaboration, developing collaboration and potential collaboration.

Conclusion

The model and the typology make it possible to analyze collaboration and identify areas for improvement. Researchers can use the indicators to determine the intensity of collaboration and link it to clinical outcomes. Professionals and administrators can use the model to perform a diagnostic of collaboration and implement interventions to intensify it.

Therapists' experiences and perceptions of teamwork in neurological rehabilitation: critical happenings in effective and ineffective teamwork

This paper reports the second part of an exploratory study into occupational therapists' and physiotherapists' perceptions and experiences of teamwork in neurological rehabilitation: the factors that were thought to influence effective and ineffective teamwork, and the meaning behind effective and ineffective teamwork in neurological rehabilitation. The study was undertaken through semi-structured interviews of 10 therapists from three different neurological rehabilitation teams based in the United Kingdom, and used the critical incident technique. Through analysis of the data, several main themes emerged regarding the perceived critical happenings in effective and ineffective teamwork. These were: team events and characteristics, team members' characteristics, shared and collaborative working practices, communication, specific organizational structures, environmental, external, and patient and family-related factors. Effective and ineffective team-work was perceived to impact on a number of levels: having implications for the team, the patient, individual team members, and the neurological rehabilitation service. The study supported the perceived value of team work within neurological rehabilitation. It also indicated the extensive and variable factors that may influence the team-working process as well as the complex and diverse nature of the process.

Improving communication in a pediatric intensive care unit using daily patient goal sheets

PURPOSE

The aim of the study was to determine if a pediatric intensive care unit (PICU) daily patient goal sheet would improve communication between health care providers and decrease length of stay (LOS).

MATERIALS AND METHODS

We evaluated a daily patient goal sheet's impact on questionnaire-based measures of effectiveness of communication, nurses' knowledge of physicians in charge, and on LOS in the PICU.

RESULTS

Four hundred nineteen questionnaires were completed by nurses and physicians before goal sheet implementation and 387 after implementation. Nurses and physicians perceived an improved understanding of patient care goals (P < .001), reported increased comfort in explaining patient care goals to parents (P < .001), and listed a higher number of patient care goals after goal sheet implementation (P < .01). Nurses identified the patient's attending physician and fellow with increased accuracy after goal sheet implementation (P < .001). Median PICU LOS was unchanged; however, mean LOS trended toward a reduction after goal sheet implementation (4.1 vs 3.7 days, P = .36). Seventy-six percent of respondents found the goal sheets helpful.

CONCLUSIONS

Using a PICU daily patient goal sheet can improve communication between health care providers, help nurses identify the in-charge physicians, and be helpful for patient care. By explicitly documenting patient care goals, there is enhanced clarity of patient care plans between health care providers.

Validación de un instrumento de medida de la intensidad de la colaboración entre los profesionales de la salud traducido al español

OBJECTIVE

To assess the validity and reliability of the Spanish version of the Intensity of Interprofessional Collaboration questionnaire (Sicotte et al).

METHOD

In the first phase, the questionnaire was translated and adapted to Spanish. The questionnaire was then distributed to a sample of 123 nurses in a Spanish University hospital. In the second phase, the construct validity, convergent validity, and internal consistency of the Spanish version of the questionnaire were determined.

RESULTS

A principal components analysis with Promax rotation suggested the existence of 4 factors that accounted for 61.47% of the total variance. Pearson's correlation coefficient between the Spanish instrument and another instrument measuring the same phenomenon was 0.718. Analysis of the internal consistency of the instrument showed a Cronbach's alpha coefficient of 0.907.

CONCLUSION

We can conclude that the intensity of interprofessional collaboration scale shows good validity and reliability in the measurement of the intensity of collaboration among professionals in healthcare teams.

Improving care through collaborative working in tissue viability

Collaboration is necessary in order to achieve the government aim of seamless care, but research has tended to focus on inter-professional, rather than intra-professional collaboration. A group of tissue viability nursesfrom across Manchester formed a collaborative group to strengthen their influence across their trusts and to achieve improvements in care through targeting specific objectives. This article discusses the rationale for collaboration, and reports an evaluation of the tissue viability nurse group's first year.

Delivering practice-based interprofessional education to community mental health teams: Understanding some key lessons

This paper describes a project that offered an interprofessional education (IPE) experience to two community mental health teams (CMHTs) based in separate inner city locations. Team members were offered three weekly workshops that aimed to enhance their understanding of interprofessional collaboration and improve their collective work as a team. A multi-method research design was employed to evaluate the impact of the workshops. Data were collected at four points in time: before, directly after, three months and 12 months following the workshops. It was found that participants enjoyed their IPE experience and reported that it was helpful in enhancing their understanding of collaboration. In addition, one team reported that the workshops had contributed to improving their communication with one another. However, two key factors constrained the overall impact of this IPE experience: a limited involvement of medical staff, which undermined the 'value' of the workshops; and a lack of senior managerial support, which impeded efforts to transfer team-based learning into practice. These findings are discussed in relation to the IPE, sociology and change management literature in order to help understand some key lessons associated with delivering practice-based IPE.

Use of Health Fairs to Develop Public Health Nursing Competencies

This paper describes a community-campus partnership for health education established through the effort of faculty, students, and the community. Health fairs designed to address issues of concern to a community agency were originally conducted with nursing students. This partnership between nursing and a community was expanded to include social work, physical therapy, and medical students. A shared learning experience was structured through the presentation of health fairs in collaboration with agencies in Burlington, Vermont. One goal of nursing education is to produce professionals who have the beginning competencies of public health nursing. Reflection on the process, relationships, and outcomes of the health fairs revealed that students attained these beginning competencies in all eight public health nursing competency domains. Combining community-campus partnerships and an interdisciplinary focus enabled nursing students to become more responsive to community needs and to learn to work collaboratively toward creating healthier communities, thus building skills required for public health nursing.

Discursive patterns in multiprofessional healthcare teams

AIM

The aim of this paper is to report a study exploring how members of multiprofessional healthcare teams talk about their team. Specifically, the team members' talk was analysed to explore the discursive patterns that emerged and their functions.

BACKGROUND

Over recent decades there has been an increasing demand in Western countries to change care organizations and to coordinate resources and professional competencies to meet the needs of patients/service users better. Because society promotes this kind of work, it may be valuable to explore the self-presentations of a multiprofessional healthcare team.

METHODS

A discourse analysis was carried out on existing empirical data from focus group interviews with a member-identified category sample comprising 32 healthcare professionals in six authentic multiprofessional teams in south-east Sweden. The analysis focused on the participants' discursive constructions of multiprofessional teamwork, on the way they talked about their group, and, in particular, on their use of the pronouns we, they and I.

FINDINGS

The constructions of 'we' by multiprofessional healthcare teams showed discursive patterns that are here referred to as knowledge synergy and trusting support, which included factors such as cross-learning and personal chemistry. The pronoun we was also used as a flexible resource to manage expertise, power and leadership within the teams, and it might also function to ease the pressure for consensus.

CONCLUSION

These discursive patterns provided powerful rhetorical resources for team members, both to affirm their choice of membership and to claim superiority in relations with the surrounding community (the others) by linking to a societal discourse that promotes collaboration.

Knowledge translation and interprofessional collaboration: Where the rubber of evidence-based care hits the road of teamwork

Knowledge-translation interventions and interprofessional education and collaboration interventions all aim at improving health care processes and outcomes. Knowledge-translation interventions attempt to increase evidence-based practice by a single professional group and thus may fail to take into account barriers from difficulties in interprofessional relations. Interprofessional education and collaboration interventions aim to improve interprofessional relations, which may in turn facilitate the work of knowledge translation and thus evidence-based practice. We summarize systematic review work on the effects of interventions for interprofessional education and collaboration. The current evidence base contains mainly descriptive studies of these interventions. Knowledge is limited regarding the impact on care and outcomes and the extent to which the interventions increase the practice of evidence-based care. Rigorous multimethod research studies are needed to develop and strengthen the current evidence base in this field. We describe a Health Canada-funded randomized trial in which quantitative and qualitative data will be gathered in 20 general internal medicine units located at 5 Toronto, Ontario, teaching hospitals. The project examines the impact of interprofessional education and collaboration interventions on interprofessional relationships, health care processes (including evidence-based practice), and patient outcomes. Routes are suggested by which interprofessional education and collaboration interventions might affect knowledge translation and evidence-based practice.

Negotiating relationship contexts in gerontological social work practice

OBJECTIVES

The objective of this study was to demonstrate the role of social workers in addressing the complex relationship and problem solving contexts typical of practice in multi-service geriatric care settings.

METHODS

We conducted a thematic analysis of the work of five social workers with five clients, their families, and the professional healthcare team, and extracted common themes across cases that illustrate the nature and timing of the interventions depending on the relationship context addressed.

RESULTS

While there were problems and issues common across relationship contexts, intervention strategies that were essential for optimizing client care and wellbeing were specific to resolving relationship conflicts in one or more of the identified relationship contexts.

The logic of collaboration in education and the human services

Collaboration is a complex intervention with multiple components. It is both a process innovation and a product innovation, and it entails institutional development and change. These and other defining features implicate its contingencies. For example, collaboration is tailor made for needs, problems, and opportunities that manifest novelty, complexity, uncertainty, and interdependent relationships. Contingencies like these signal important constraints. For example, collaboration exacts steep transaction costs. Its potential benefits justify these costs and serve as incentives for its development. In fact, collaboration may be a defining feature of competent and optimal practice, and the failure to collaborate may be indicative of negligence and malpractice.

Collaboration: Aligning resources to create and sustain partnerships

Academic-service partnerships are the future. These partnerships require a new paradigm and new practice models that necessitate change in how and where decisions are made as well as who is accountable for both the decisions and the outcomes of those decisions. The role of organizational leaders in this new paradigm becomes aligning resources to create and sustain partnerships. Partnerships are relationships and are only as effective as the communication between all entities. Decision-making is an important outcome of partnerships, yet there is little research regarding specific behavioral strategies that promote quality problem solving and decision-making. This paper extends the work of organizational theorist Ralph Stacey by proposing an event-driven typology of behavioral strategies for problem solving. The typology can assist organizational leaders to align resources for best practices in academic-service partnerships and be used as a framework for future research.

The dying patient in the ICU: role of the interdisciplinary team

Expert opinion supports the application of broad interdisciplinary team approaches to the care of the dying patient in the intensive care unit (ICU). Current literature contains many suggestions about how core team members-physicians, nurses, and patients/family members-could systematically enhance interdisciplinary collaboration in the care of the dying patient. In the few studies of ICU interdisciplinary collaborative care of the dying patient, investigator shave demonstrated improvement in care. In addition, ethics consultants and interdisciplinary palliative care teams, working with the core team members, have improved care for the dying. Further studies are needed to document alternative interdisciplinary models for achieving improved and durable patient, family,and provider outcomes in the care of the dying ICU patient.

An interprofessional problem-based learning course on rehabilitation issues in HIV

This study examined students' perceptions of their learning through participation in an interprofessional problem-based course on rehabilitation and HIV. Students representing five health professions participated in an eight-week tutorial course. Qualitative analysis of journals that the students completed throughout the course, and of interviews of the students at completion of the course, revealed that they valued their learning experience. Students gained an appreciation of the roles of others and developed a sense of confidence through justifying their professional role. Through the interprofessional discussions, students were able to increase the breadth and depth of their learning and also gained a rehabilitation perspective. Learning related to HIV and rehabilitation is ideally suited to an interprofessional, problem-based environment.

Improving communication in the ICU using daily goals

BACKGROUND

Clear communication is imperative if teams in any industry expect to make improvements. An estimated 85% of errors across industries result from communication failures.

PURPOSE

The purpose of this study was to evaluate and improve the effectiveness of communication during patient care rounds in the intensive care unit (ICU) using a daily goals form.

DESIGN

We conducted a prospective cohort study in collaboration with the Volunteer Hospital Association (VHA), Institute for Healthcare Improvement (IHI), and Johns Hopkins Hospital's (JHH) 16-bed surgical oncology ICU. All patients admitted to the ICU were eligible. Main outcome variables were ICU length of stay (LOS) and percent of ICU residents and nurses who understood the goals of care for patients in the ICU. Baseline measurements were compared with measurements of understanding after implementation of a daily goals form.

RESULTS

At baseline, less than 10% of residents and nurses understood the goals of care for the day. After implementing the daily goals form, greater than 95% of nurses and residents understood the goals of care for the day. After implementation of the daily goals form, ICU LOS decreased from a mean of 2.2 days to 1.1 days.

CONCLUSION

Implementing the daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU LOS. The use of the daily goals form has broad applicability in acute care medicine.

Evaluation of the effect of co-financing on collaboration between health care, social services and social insurance in Sweden

In this paper, we present an ongoing research project aimed to determine the impact of co-financing on collaboration around patients with musculoskeletal disorders. A trial legislation that allows the social insurance, social services and health care services to unite in co-financing under joint political steering has been tested in different areas in Sweden. In a series of studies, we compare collaboration processes and health outcome for patients with musculoskeletal disorders between health centres with co-financing projects and control health centres without co-financing projects. In this paper the studies are described and some preliminary results are discussed.

Working together but apart: barriers and routes to nurse--physician collaboration

The authors argue that the aircraft safety model may be of limited relevance for health care and suggest strategies for greater collaboration between nurses and physicians in the care of patients.